Post Type Archives: Topics

Contrast-induced nephropathy is an acute renal failure occurring within 24-48 hours of exposure to intravascular radiographic contrast material not related to other causes.
It is the third most common cause of hospital-acquired acute renal injury. The first and second cause is surgery and hypotension, respectively.
Diagnostic criteria-
• Rise in serum creatinine (Scr) levels of more than 25% or ≥0.5 mg/dl (44 μmol/l) from baseline within 48 h of contrast media exposure with the exclusion of other causes of acute kidney injury
• Signs of acute tubular necrosis
• Fractional excretion of sodium (FeNA) less than 1
Risk factors
• Chronic Kidney Disease or preexisting impairment of renal function is the most common risk factor.
• Diabetic nephropathy
• Proteinuria- the excess protein in tubular lumen accumulates with contrast media and causes tubular obstruction. Hypoalbuminemia increases free drug concentration in the blood that increases the risk of nephrotoxicity. (clue: most drugs are bound to albumin).
• Multiple Myeloma -It has high amounts of protein in the tubular lumen. The concomitant use of contrast material causes the accumulation of precipitated contrast media and myeloma protein in the tubular lumen. This accumulated protein, contrast media, and desquamated apoptotic tubular cells together cause tubular obstruction and acute tubular injury (obstructive nephropathy).
• Reduced intravascular volume (congestive heart failure, liver cirrhosis, or abnormal fluid losses) causes prolonged hypotension. It contributes to a prerenal reduction in renal perfusion.
• High Osmolality Contrast Media
• Amount of contrast Media

Sodium-glucose cotransporter -2 Inhibitors (SGLT-2 i) are newer drugs in the category of glucose-lowering drugs (antihyperglycemics). The SGLT-2 inhibitors block the SGLT-2 protein in proximal convoluted tubular cells (PCT cells) and inhibit the reabsorption of glucose and sodium, consequently reducing blood glucose and sodium levels.

Nephrogenic systemic fibrosis (NSF), as the name implies, is a systemic fibrosis involving multiple organs and tissues due to nephrogenic pathology (chronic/acute renal failure).
Previously, NSF was known as nephrogenic fibrosing dermopathy because of peculiar skin manifestation detected at the time of discovery of this entity. But now it is discovered that it involves other organs and tissues, so Nephrogenic systemic fibrosis is a better term to describe the disease.

Metabolic acidosis is a condition where the body’s acid load is so high that it starts to affect the normal functioning of the body. It is defined as serum bicarbonate levels < 22 mEq/L (or serum tCO2 levels < 22 mEq/L). The lungs and kidneys play a major role in acid-base maintenance. Serum bicarbonate and serum tCO2 Serum bicarbonate travels through the body in the form of carbon dioxide gas. High serum bicarbonate gives high levels of serum total carbon dioxide (tCO2), and low serum bicarbonate levels give low levels of serum tCO2. That’s why the serum tCO2 is a surrogate assessment marker for serum bicarbonate levels. Normal kidney removes excess acid load by excreting more ammonia and titratable acids. In chronic kidney disease, the kidney cannot excrete excess acid due to a reduced number of functioning nephrons. It leads to the accumulation of acid in the blood and metabolic acidosis. Metabolic acidosis and serum bicarbonate levels The body has a carbonic acid-bicarbonate buffer system. It helps in maintaining the pH balance. The lungs and kidneys play a crucial role in regulating the acid-base balance using this buffer system.

Bronchiectasis is an obstructive lung disease characterized by chronic necrotizing damage of smooth muscles and elastic support tissue of bronchi and bronchioles. It consequently leads to permanent irreversible dilation of bronchi and bronchioles. The involved bronchi and bronchioles are filled with excessive mucus and lead to reduced airflow. The bronchial dilation can be cylindrical (most common), varicose, or cystic.
The lung involvement can be focal or diffused.
• Focal – seen in tumor or foreign body impaction, bronchiectasis is localized to the obstructed lung segment.
• Diffused – seen in infection or immunodeficiency state, widespread bronchiectasis involving the entire lung.
Etiopathogenesis
Chronic necrotizing inflammation of the bronchi, caused by bronchial obstruction/ infection or impaired mucociliary clearance, is central to the pathogenesis of most cases of bronchiectasis.
Obstruction- bronchial obstruction due to tumor (internal/ external), lymphadenopathy, or foreign body
Infection – tuberculosis, staphylococcus aureus, pseudomonas aeruginosa
Impaired Mucociliary Clearance
Cystic fibrosis
Mutation in CFTR gene → Reduced chloride ion secretion in the mucus of respiratory epithelium → Thick and viscid mucus → Cilia cannot move smoothly in thick viscid mucus →Impaired Mucociliary clearance →Reduced removal of pathogens →Superimposed infection→ Chronic necrotizing inflammation → Bronchial wall damage → Permanent bronchial dilation → Bronchiectasis.
Please read more about Cystic Fibrosis – Creative Med Doses
Primary ciliary dyskinesia
Autosomal recessive mutation → Defect in motile cilia production or function → Immotile cilia is unable to sweep mucus → Impaired Mucociliary clearance→ Reduced removal of pathogens → Superimposed infection → Chronic necrotizing inflammation → Bronchial wall damage → Permanent bronchial dilation → Bronchiectasis.
Immotile cilia also lead to infertility and dextrocardia
Kartagener syndrome
• Situs inversus
• Chronic sinusitis
• Bronchiectasis
Read about Kartagener syndrome where cilia doesn’t move – Creative Med Doses

Clinical features
• Persistent productive cough
• Expectoration of copious purulent foul (fetid) smelling sputum
• Tenacious sputum
• Acute exacerbation is associated with sputum changes (increased purulence and volume)
• Hemoptysis (when nearby vessels erode due to chronic necrotizing inflammation)
• Wheezing and crackling on auscultation
• Clubbing of digits due to chronic hypoxemia
Diagnosis
Based on clinical presentation and consistent radiological findings.
Chest X-ray – Shows tram tracks sign (thickened bronchial wall)
High-Resolution Computed Tomography (HRCT)- Imaging modality of choice
• Tram track sign- Bronchial wall thickening (parallel tram lines)
• Tree bud appearance – Dilated and thickened bronchial wall with intraluminal inspissated mucus, pus, and fluid resembling a budding tree.
• Signet ring sign- In bronchiectasis, a cross-sectional area of the airway is at least 1.5 times that of the adjacent vessel, and it appears like a signet ring. The bronchus and artery diameter should be the same size, but in bronchiectasis, the dilated bronchi diameter is more than 1.5 times that of the adjacent artery. It gives a signet ring appearance.
• Lack of bronchial tapering (the presence of tubular structures within 1 cm from the pleural surface)
• Cystic dilation of bronchi
Bronchoscopy is done to rule out foreign body or mass causing airway obstruction, especially in cases with focal bronchiectasis.
Pulmonary function testing for functional assessment of the patients – It can be an obstructive, restrictive, or normal pattern.

Polycythemia vera (PV) is a chronic myeloproliferative disorder with trilineage proliferation (erythroid, granulocytic, megakaryocytic).
It leads to an increased number of RBCs, granulocytes (Neutrophils, basophils, and eosinophils), and Platelets.
It is associated with an absolute increase in RBC mass.
PV must be differentiated from relative polycythemia, which results from hemoconcentration due to diarrhea/ vomiting. Polycythemia vera, in contrast to reactive polycythemia, is associated with low levels of serum erythropoietin (EPO).
Genetics
Most cases (95%) are associated with JAK2 V617F mutation or JAK2 axon 12 mutation on the short arm of the 9th chromosome.
JAK2 617F mutation is also seen in nearly 50% of cases of –
• Essential thrombocythemia (ET)
• Primary myelofibrosis (PMF)
Pathogenesis
JAK2 V617F point mutation or JAK2 axon 12 mutation on the short arm of the 9th chromosome → constitutive activation on JAK2/STAT signaling pathway → sharply lowers the dependence of hematopoietic cells on growth factors for growth and survival → Dysregulated activation of JAK-STAT signaling pathway → Proliferation and differentiation of Hematopoietic progenitor cells → Too much increase in RBC, Granulocytes, and Platelets (panmyelosis) → most clinical signs and symptoms are related to an absolute increase in red cell mass → Polycythemia Vera (Primary polycythemia)

Ureterocele is a congenital dilation of the intravesicular portion of a ureter. In this anomaly, the part of the distal ureter which enters the bladder balloons at its opening into the bladder, forming a sac-like pouch. It appears balloon-shaped on cystoscopy. Most ureteroceles get prenatal diagnosis while doing routine antenatal Ultrasound. The ureterocele causes prenatal hydronephrosis. And, in the child, it causes frequent urinary tract infections because it is associated with vesicoureteral reflux.
It can be of two types –
A ureterocele is a congenital dilation of the intravesicular portion of a ureter. In this anomaly, the part of the distal ureter which enters the bladder balloons at its opening into the bladder, forming a sac-like pouch. This sac-like enlargement usually interferes with the flow of urine.

Complement-dependent cytotoxicity (CDC) crossmatch is the most commonly performed test to determine whether one should proceed with transplantation.
In the complement-dependent cytotoxicity (CDC) crossmatch test donor’s lymphocytes from blood or lymphoid tissue are incubated with recipient serum, followed by mixing rabbit complement and dyes to distinguish dead from living donor cells.
The cell membrane is not intact in lysed dead cell, so it will take up the dye and stain red (or whatever color the dye contains).
If the recipient’s serum has preformed antibodies against the donor’s antigens, there will be cell lysis after adding complement, and the dead cells will take up the dye. It is a positive crossmatch if there is cell lysis of more than 20 percent of donor cells (lymphocytes). Avoid transplantation from such donors. Positive CDC crossmatch is an absolute contraindication for renal transplantation.
It is a negative crossmatch if the donor’s lymphocytes show no or minimal cell lysis. One may go with transplantation because the donor and recipient are compatible, and the chances of early graft rejection are low.

Tubulointerstitial nephritis (TIN)
Introduction
Tubulointerstitial diseases can be of two types- Primary and Secondary
Secondary tubulointerstitial disease: Inflammation or fibrosis of the renal interstitium and atrophy of the tubular compartment following the glomeruli or vascular diseases.
Primary Tubulointerstitial Nephritis (TIN)- primarily affects the tubules and interstitium, with relative sparing of the glomeruli and renal vessels. Glomerulus and renal vessels get involved in the later stages of the disease.
Primary Tubulointerstitial nephritis can be acute and chronic tubulointerstitial nephritis (TIN).
Acute Tubulointerstitial Nephritis (ATIN)-Tubulo-interstitial inflammation causes a rapid decline in renal function within days to weeks. It is reversible with early diagnosis and prompt treatment.
Causes and Pathogenesis of ATIN
Drug-induced TIN
Following drugs are the most common etiological factor of Drug-induced ATIN-
• Penicillin
• Rifampicin
• Diuretics
• Proton pump inhibitors
• NSAIDs
• Sulfa Drugs
• Phenytoin
Tubular secretion of the drug→ Drug act as a HAPTEN →Drug binds with the cytoplasmic or extracellular components of Tubular Cells →Drug becomes IMMUNOGENIC → Immune-mediated tubular-interstitial damage (Type I hypersensitivity or Type IV hypersensitivity).
Type I hypersensitivity
IgE mediated Tubular and Interstitial damage
Classical Triad of Drug-Induced TIN
• Eosinophilia
• Rashes
• Fever
Type IV hypersensitivity – T Cell-mediated Tubular and interstitial damage

Autoimmune Diseases
Autoantibodies and immune complexes lead to Immune-mediated tubular-interstitial damage.
Most common autoimmune diseases associated with Acute TIN-
• Tubulointerstitial Nephritis and Uveitis Syndrome (TINU)
• Sjogren Syndrome
• SLE
Acute Tubular Obstruction
Light Chain Cast Nephropathy (LCCN), also known as Myeloma Kidney/ Crystal Nephropathy (uric acid/medications) →Acute tubular obstruction →Tubular injury and inflammation → Tubulointerstitial nephritis and acute tubular necrosis if left untreated →Acute Renal Failure.
Microbial Infection
Microbial infection (bacteria/virus/fungi) → stimulates tubulointerstitial inflammation →Acute TIN.
The microbial infection causes ATIN only in Preexisting Tubular obstruction /Vesicoureteral Reflux or Immunocompromised cases.

Multiple Myeloma (MM) is a plasma cell dyscrasia associated with malignant plasma cells producing excessive monoclonal proteins (immunoglobulin and free light chain).
Renal injury is commonly associated with MM and has very high mortality rates. More than 50% of cases of MM present with renal involvement.